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General NPI Number Information
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NPI Number | 1396064416
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Entity Type | Organization
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Legal Business Name | CHARLES E MOISAN JR MD PC
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Dates
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Enumeration Date | 05/28/2010
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Last Update Date | 06/01/2010
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Provider Practice Location Address
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Address Line | 80 PARK ST
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City | ELIZABETHTOWN
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State | NY
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Zip | 12932-2304
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Country | US
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Telephone | 518-873-6340
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Fax |
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Provider Business Mailing Address
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Address Line | 80 PARK ST
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City | ELIZABETHTOWN
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State | NY
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Zip | 12932-2304
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Country | US
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Telephone | 518-873-6340
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | DIANNE C AHRENT
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Credential |
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Telephone | 518-562-3204
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 102273
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License Number State | NY
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